An elderly woman is having a casual conversation with her neighbour who is a practising family physician, and says she is dissatisfied with the care she is receiving at a nearby walk-in clinic. She asks the physician whether he is able to accept her as a new patient in his practice. The patient briefly describes her medical conditions, which require ongoing treatment and monitoring. The physician replies that he is not currently accepting new patients, though he does maintain a wait list of prospective patients. She asks him to put her on the list, despite being advised the wait could be at least six months. Feeling sympathetic to his neighbour, the following day the physician instructs his office assistant to put this individual near the top of the wait list in an effort to reduce her wait time. Is this action appropriate, given the circumstances?
Timely access to physician care is a challenge for Canadians in many parts of the country, leaving physicians to make the sometimes-difficult decision about whether or not to accept new patients. Already dealing with heavy workloads, physicians face the moral dilemma of possibly turning away people seeking care in order to maintain a sustainable and well-managed practice.
Indeed, many physicians—whether they are in primary care practice such as family physicians, or consultant physicians who typically only accept patients via referrals—encounter this challenge. Differences in how these two groups accept new patients reflect the different nature of the care provided, and in this article we focus on the former group—those in primary care practice.
While there are some variations, regulatory authority (College) policies on accepting new patients share many similar elements that are grounded in physicians’ ethical, professional and legal responsibilities. Physicians should be mindful of these elements when they receive a request for ongoing clinical care from an individual with whom there is no existing doctor-patient relationship, including:
- urgency and need
- scope of practice and clinical competence
- wait lists.
Urgency and need
Physicians are generally not obligated to treat any individual seeking non-urgent or non-emergent care. That said, physicians who receive a request to accept a new patient should consider whether the individual requires emergency care. While providing emergency treatment does not necessarily imply the formation of an ongoing doctor-patient relationship, providing such care when needed is consistent with the CMA Code of Ethics and Professionalism, which advises physicians to "provide whatever appropriate assistance you can to any person who needs emergency medical care."1
The Colleges offer guidance that is more specific in this area. The College of Physicians and Surgeons of British Columbia, for example, states that "in medically emergent or urgent situations, registrants are expected to provide whatever medical care is appropriate, considering the patient’s safety, scope of practice and available options."2
In some circumstances, it may be appropriate for physicians to prioritize access to care for individuals with greater needs or complex conditions. The College of Physicians and Surgeons of Ontario (CPSO) advises that physicians should use their professional judgment to determine whether prioritization based on need is appropriate, taking into account social factors that may influence the person’s health outcomes such as the individual’s housing, food security, employment, and income.3
Scope of practice and clinical competence
Physicians accepting new patients should not refuse individuals solely due to the presence of a complex or chronic health problem or if an individual requires more time than another patient with fewer medical needs. Nevertheless, if the individual’s care needs are not within the physician’s scope of practice or clinical competence, this would generally be considered grounds for refusing a prospective patient. However, because of the broad scope of practice of primary care physicians, scope of practice would not usually be an appropriate ground to refuse a prospective patient.
Physicians are bound by the human rights legislation of their province or territory. As well, the CMA Code of Ethics and Professionalism states that physicians should accept patients “without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status).”1 Nevertheless, "this does not abrogate the physician’s right to refuse to accept a patient for legitimate reasons."1
If refusing a prospective patient’s request, physicians should consider the impact of such a refusal on the patient. Some individuals may interpret a refusal as discrimination, even when this is not the physician’s intention. For this reason, it is important for physicians to ensure that they or their administrative staff are equipped to clearly and respectfully communicate the reasons for a refusal, thereby dispelling possible perceptions of discrimination.
Wait lists and patients’ family members
If a physician is accepting new patients, the principle of first-come, first-served should generally apply for patients in a similar situation. This also means that prospective patients on a wait list should be accepted into a practice in the same order in which they were added to the list. When using a wait list, clearly communicating the expected waiting period to new prospective patients helps manage expectations and diffuse potential misunderstandings.
It is generally justified to accept members of existing patients’ families into a practice, even when a physician is not otherwise accepting new patients. Caring for patients’ family members may provide a broader view of family history, which could contribute to better health outcomes.
The bottom line
- The decision to either accept or refuse a new patient should always be made in good faith and in keeping with your College’s policy on accepting new patients.
- Your decision may depend on such factors as whether your practice is accepting new patients and whether you are qualified to provide the care requested or expected to be needed.
- If you decide to not provide treatment or not accept a new patient to your practice, the decision should be made in non-emergency situations only and in a way that applies to all prospective patients equally.
- Discuss your decision to not accept a new patient with the individual respectfully and honestly, and document this in your files.
In our introductory vignette, while the patient clearly needed to be followed by a physician, her immediate needs were not urgent. By placing her ahead of others on the wait list, other patients who had been waiting longer and those with more serious problems would be adversely affected. In this example, having determined the prospective patient’s needs and current situation, the best approach might have been to add her to the wait list on a first-come, first-served basis, or if possible to offer a referral to another physician.
- Canadian Medical Association [Internet]. Ottawa (CA): CMA; 2018 (reviewed 2022 June). CMA Code of Ethics and Professionalism [cited 2022 June]. Available from: https://policybase.cma.ca/viewer?file=%2Fmedia%2FPolicyPDF%2FPD19-03.pdf#page=1
- College of Physicians and Surgeons of British Columbia [Internet]. Vancouver (CA): CPSBC; 2012 Nov (updated 2022 May). Practice Standard, Access to Medical Care without Discrimination [cited 2022 June]; [3 screens]. Available from: https://www.cpsbc.ca/files/pdf/PSG-Access-to-Medical-Care.pdf
- The College of Physicians and Surgeons of Ontario [Internet]. Toronto (CA): CPSO: 2008 Nov (updated 2017 May). Accepting New Patients [cited 2022 June]; [4 screens]. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Accepting-New-Patients